- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,647.93 / $2,647.93 / $2,647.93
| Professional | | $2,647.93 | $2,647.93 | $2,647.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,421.00 / $6,505.00 / $10,472.00
| Professional | | $5,421.00 | $6,505.00 | $10,472.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,407.91 / $4,377.63 / $6,397.79
| Professional | | $3,407.91 | $4,377.63 | $6,397.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,812.05 / $7,624.10 / $9,010.29
| Professional | | $3,812.05 | $7,624.10 | $9,010.29 |